- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.71 / $809.19 / $1,119.65
| Professional | | $682.71 | $809.19 | $1,119.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.54 / $954.38 / $1,423.01
| Professional | | $689.54 | $954.38 | $1,423.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.14 / $1,195.54 / $1,578.27
| Professional | | $994.14 | $1,195.54 | $1,578.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.00 / $4,571.00 / $7,350.00
| Facility | | $2,569.00 | $4,571.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.51 / $1,094.01 / $1,686.92
| Professional | | $682.51 | $1,094.01 | $1,686.92 |